2008 performance improvement project: improving the documented use of aspirin in msho/msc/msc+...

2008 Performance Improvement 2008 Performance Improvement Project:Project:

Improving the Improving the documenteddocumented use use of aspirin in MSHO/MSC/MSC+ of aspirin in MSHO/MSC/MSC+

seniors with diabetes or ischemic seniors with diabetes or ischemic heart diseaseheart disease

Developed by Jackson Thatcher MD FACC FSCAIDeveloped by Jackson Thatcher MD FACC FSCAI

Presented by Theresa Zeman NPPresented by Theresa Zeman NP

2008 Performance Improvement Project2008 Performance Improvement Project

Scope, Evidence & DisclosuresScope, Evidence & Disclosures

The scope of this project is limited to The scope of this project is limited to seniors age 65-84 covered under the seniors age 65-84 covered under the senior Medicaid plans: Minnesota Senior senior Medicaid plans: Minnesota Senior Health Options (MSHO), Minnesota Senior Health Options (MSHO), Minnesota Senior Care (MSC) or Minnesota Senior Care (MSC) or Minnesota Senior Care Plus (MSC+)Care Plus (MSC+)

The scientific statements in this PowerPoint The scientific statements in this PowerPoint are drawn from the Project Executive are drawn from the Project Executive

Summary and References and ACC-AHA Summary and References and ACC-AHA Cardiovascular Disease GuidelinesCardiovascular Disease Guidelines

Why Diabetics and Patients with Why Diabetics and Patients with Vascular disease?Vascular disease?

Diabetics have a comparable risk of MI Diabetics have a comparable risk of MI to that of matched non-diabetics to that of matched non-diabetics with prior MIwith prior MI

All diabetics and patients with vascular All diabetics and patients with vascular disease have an evidence-based disease have an evidence-based guideline supported Class I indication guideline supported Class I indication for aspirinfor aspirin

Why Aspirin?Why Aspirin?

Aspirin is fundamental to the care of Aspirin is fundamental to the care of patients with cardiovascular diseasepatients with cardiovascular disease


There are very few patients with an There are very few patients with an absolute contraindication to aspirin absolute contraindication to aspirin

Approximately 98% of Approximately 98% of patients may have a patients may have a

trial trial of aspirin therapy of aspirin therapy when when indicatedindicated


Aspirin is the only essential drug used in Aspirin is the only essential drug used in vascular disease and diabetes that is vascular disease and diabetes that is not not well documented by claims datawell documented by claims data

Claims data indicate senior Medicaid Claims data indicate senior Medicaid patients and their providers fail to use the patients and their providers fail to use the OTC aspirin benefit provided by their planOTC aspirin benefit provided by their plan

Why Aspirin?Why Aspirin?Poor utilization of the senior Medicaid Poor utilization of the senior Medicaid

OTC aspirin benefit leaves aspirin use OTC aspirin benefit leaves aspirin use grossly grossly under documentedunder documented

Many of these undocumented seniors Many of these undocumented seniors are probably taking aspirin, but could are probably taking aspirin, but could utilize their OTC benefit to obtain their utilize their OTC benefit to obtain their aspirin at little or no costaspirin at little or no cost


Utilizing the senior OTC aspirin benefit Utilizing the senior OTC aspirin benefit would provide data documenting the would provide data documenting the quality of care in eligible patientsquality of care in eligible patients

Platelets and ThrombosisPlatelets and Thrombosis

Platelets are small cell-like particles in the Platelets are small cell-like particles in the blood that help patch leaks and promote blood that help patch leaks and promote blood-clottingblood-clotting

In diseased arteries platelet thrombi In diseased arteries platelet thrombi (clumps) can completely block the (clumps) can completely block the narrowed vessel resulting in stroke or narrowed vessel resulting in stroke or heart attackheart attack

Platelets and ThrombosisPlatelets and Thrombosis

Cholesterol rich Cholesterol rich PlaquePlaque

Platelet Clump Platelet Clump (White Thrombus) (White Thrombus) usually at a site of usually at a site of plaque fibrous cap plaque fibrous cap rupturerupture

Thin fibrous cap Thin fibrous cap prone to ruptureprone to rupture

So what happens if this occurs?So what happens if this occurs?

Plaque rupture results in platelet activationPlaque rupture results in platelet activation

Activated platelets release chemical signals Activated platelets release chemical signals that allow other platelets to attachthat allow other platelets to attach


Platelets release additional chemicals that Platelets release additional chemicals that constrict blood vessels slowing blood flow constrict blood vessels slowing blood flow and allowing more platelets to accumulateand allowing more platelets to accumulate

Activated platelets start the clotting cascade Activated platelets start the clotting cascade and red clot formsand red clot forms


Platelet thrombi (clumps) break loose from Platelet thrombi (clumps) break loose from the white clot and embolize (clog) small the white clot and embolize (clog) small branches downstream causing branches downstream causing microvascular occlusion which results in microvascular occlusion which results in rest angina (chest pain at rest) and rest angina (chest pain at rest) and eventual injury to heart muscleeventual injury to heart muscle

The entire vessel may close resulting in a The entire vessel may close resulting in a full-blown heart attackfull-blown heart attack

Plaque RupturePlaque Rupture

Fibrous plaqueFibrous plaque

Semi liquid lipid Semi liquid lipid core under thin core under thin capcap

Extruded lipid Extruded lipid after cap ruptureafter cap rupture

Developing Developing thrombin and blood thrombin and blood cell clot (red clot)cell clot (red clot)

Platelet thrombus Platelet thrombus (white clot)(white clot)

Platelet embolusPlatelet embolus

Factors promoting plaque rupture Factors promoting plaque rupture (wall stress, inflammation, thin cap (wall stress, inflammation, thin cap and large lipid core)and large lipid core)

Angiogram of Angiogram of Acute Myocardial InfarctionAcute Myocardial Infarction

Acutely occluded right coronary artery


Partial flow restored


After stenting restored full blood flow stopping further damage to heart muscle


Heart pumping after normal blood flow restored

So How Does Aspirin Reduces the So How Does Aspirin Reduces the Risk of Heart Attacks and Strokes?Risk of Heart Attacks and Strokes?

Aspirin Aspirin irreversiblyirreversibly binds to cyclo- binds to cyclo-oxygenase (COX-1) on the plateletoxygenase (COX-1) on the platelet

Aspirin blocked COX-1 cannot catalyze Aspirin blocked COX-1 cannot catalyze the formation of thromboxane A-1, which the formation of thromboxane A-1, which stimulates platelet activation stimulates platelet activation

How Aspirin Reduces the Risk of How Aspirin Reduces the Risk of Heart Attacks and StrokesHeart Attacks and Strokes

Aspirin treated platelets are much less Aspirin treated platelets are much less likely to activate and clump togetherlikely to activate and clump together

Since there are over 80 separate Since there are over 80 separate pathways that initiate platelet activation pathways that initiate platelet activation aspirin therapy is not 100% effective in aspirin therapy is not 100% effective in stopping platelet activation and clumpingstopping platelet activation and clumping

How Drugs Reduce the Risk of How Drugs Reduce the Risk of Heart Attacks and StrokesHeart Attacks and Strokes

Some other agents that reduce platelet Some other agents that reduce platelet clumping include:clumping include:

Clopidogrel (PlavixClopidogrel (Plavix®®))Didpyridamole (PersantineDidpyridamole (Persantine®®, and combined , and combined

with aspirin in Aggrenoxwith aspirin in Aggrenox®®) ) Intravenous glycoprotein receptor inhibitors Intravenous glycoprotein receptor inhibitors

such as abciximab (ReoProsuch as abciximab (ReoPro®®) or eptifibitide ) or eptifibitide (Integrilin(Integrilin®®))

How Drugs Reduce the Risk of How Drugs Reduce the Risk of Heart Attacks and StrokesHeart Attacks and Strokes

Some other agents that reduce platelet Some other agents that reduce platelet clumping include:clumping include:

Omega-3 fatty acids (Fish Oil)Omega-3 fatty acids (Fish Oil)Some calcium channel blockersSome calcium channel blockersBeta-blockersBeta-blockersNitratesNitratesFibrin split products - created when Fibrin split products - created when

streptokinase is used as a thrombolytic streptokinase is used as a thrombolytic (‘clot busting’ drug)(‘clot busting’ drug)

How Many Seniors are at Risk?How Many Seniors are at Risk?

Risk increases in lower income Risk increases in lower income populationspopulationsSubstantial numbers of seniors Substantial numbers of seniors

have lower income have lower income

How Many Seniors are at Risk?How Many Seniors are at Risk?

A healthy lifestyle: principally reduced A healthy lifestyle: principally reduced smoking and blood pressure treatment smoking and blood pressure treatment delays the onset of vascular disease delays the onset of vascular disease until later in life until later in life

But vascular disease remains a But vascular disease remains a leading cause of morbidity and leading cause of morbidity and mortality even in seniors who were mortality even in seniors who were considered healthy through middle ageconsidered healthy through middle age

How Many Seniors are at Risk?How Many Seniors are at Risk?Hypertension, obesity, dyslipidemia and Hypertension, obesity, dyslipidemia and

type 2 diabetes (metabolic syndrome) type 2 diabetes (metabolic syndrome) pose potent increasing risk factors in pose potent increasing risk factors in the elderlythe elderly

20% of seniors are currently diabetic20% of seniors are currently diabeticThis number may approach 40% as This number may approach 40% as

the obesity epidemic peaks in seniorsthe obesity epidemic peaks in seniors

Seniors who live long enough will likely Seniors who live long enough will likely develop vascular diseasedevelop vascular disease

What is the Current Data for Use?What is the Current Data for Use?

Patients with prior MI Patients with prior MI oror diabetic diabetic patients have a 20% risk of patients have a 20% risk of new/recurrent cardiovascular events new/recurrent cardiovascular events within 3 yearswithin 3 years

Patients with diabetes Patients with diabetes andand prior MI prior MI have a risk of over 45%have a risk of over 45%


Aspirin use lowers that risk Aspirin use lowers that risk by about 25%by about 25%35% reduction nonfatal MI35% reduction nonfatal MI25% reduction nonfatal stroke25% reduction nonfatal stroke15% reduction in vascular and other 15% reduction in vascular and other

cause of deathcause of death


For every 1000 indicated individuals treated For every 1000 indicated individuals treated with low dose aspirin, 10-20 fewer vascular with low dose aspirin, 10-20 fewer vascular events are expected events are expected each yeareach year

What is the Risk of Treatment?What is the Risk of Treatment?

Aspirin Aspirin causes causes serious bleeding including serious bleeding including hemorrhagic stroke in 1-2% of patients hemorrhagic stroke in 1-2% of patients treated with low dose aspirintreated with low dose aspirin


Statistically, Statistically, unless vascular disease or unless vascular disease or diabetes is presentdiabetes is present low dose aspirin therapy low dose aspirin therapy provides no benefit in men prior to age 50 provides no benefit in men prior to age 50 and no benefit in and no benefit in womenwomen prior to age 60 prior to age 60


Seniors with vascular disease or diabetes Seniors with vascular disease or diabetes have unequivocal benefit unless excess risk have unequivocal benefit unless excess risk is identifiedis identified

So I haveSo I have

Good News and Bad News,Good News and Bad News,

Which news do you want first?Which news do you want first?

Lecturer’s prerogativeLecturer’s prerogative

First the Bad NewsFirst the Bad News

The Bad NewsThe Bad News

Medicine can be expensiveMedicine can be expensive

OK then,OK then, so what’s so what’s The Good News?The Good News?

The Good NewsThe Good News

At least we can afford At least we can afford aspirinaspirin

Relative Generic Costs per YearRelative Generic Costs per Year

Aspirin Aspirin $5.00 $5.00 X X Lisinopril Lisinopril $30.00 $30.00 6X 6X Carvedilol (Target/Sam’s)Carvedilol (Target/Sam’s) $48.00 $48.00 10X10X Lovastatin (Target/Sam’s)Lovastatin (Target/Sam’s) $48.00 $48.00 10X10X Metoprolol (QD formulation) $75.00 Metoprolol (QD formulation) $75.00 15X15X SimvastatinSimvastatin $200.00 40X$200.00 40X Atorvastatin (not generic)Atorvastatin (not generic) $1300.00 $1300.00 260X260X Clopidogrel (not generic) $1900.00 Clopidogrel (not generic) $1900.00 380X 380X

What are the Current Criteria for Use?What are the Current Criteria for Use?What is Anticipated in the Future?What is Anticipated in the Future?

Aspirin, along with beta-blocker, converting Aspirin, along with beta-blocker, converting enzyme inhibitor and a statin are AHA-ACC enzyme inhibitor and a statin are AHA-ACC Guideline Indicated (Class 1) in vascular disease Guideline Indicated (Class 1) in vascular disease and diabetes unless contraindicatedand diabetes unless contraindicated

Studies in diabetics like the ACCORD trial Studies in diabetics like the ACCORD trial examining the results of optimal glucose control examining the results of optimal glucose control on top of hypertension control, lipid treatment, on top of hypertension control, lipid treatment, beta blocker, and aspirin therapy beta blocker, and aspirin therapy maymay reduce reduce cardiovascular events by over 50% cardiovascular events by over 50%

results anticipated by 2011results anticipated by 2011

Where Does All This Lead?Where Does All This Lead?

A recent early report from ACCORD A recent early report from ACCORD indicates that the most aggressive glucose indicates that the most aggressive glucose lowering arm: HgBA1c lowering arm: HgBA1c << 6.5 was 6.5 was associated with more deaths than associated with more deaths than standard care: HgBA1c standard care: HgBA1c << 7.4 7.4

Because of this the treatment arm was Because of this the treatment arm was softened to aim for an HgbAIc softened to aim for an HgbAIc < < 7.07.0


While aggressive glucose lowering may While aggressive glucose lowering may not have been tolerated by some, not have been tolerated by some, researchers expect both arms will do researchers expect both arms will do better than ‘average’ care which still tends better than ‘average’ care which still tends to be suboptimal.to be suboptimal.

MCOs don’t need to wait until 2011 MCOs don’t need to wait until 2011 to prepare to compare their results in to prepare to compare their results in theirtheir ‘average’ diabetics to the ACCORD ‘average’ diabetics to the ACCORD populations and see where they standpopulations and see where they stand


If we plan now we could have If we plan now we could have a real jump on a a real jump on a

DHS DHS SeniorSenior performance performance improvement project for 2011!improvement project for 2011!

Changing LanesChanging Lanes

Moving from what we need to do,Moving from what we need to do,

To what may make it difficult to accomplish To what may make it difficult to accomplish

Despite our best effort, tools, and successes to dateDespite our best effort, tools, and successes to date

Why is ASA Treatment Why is ASA Treatment DocumentationDocumentation so Poor? so Poor?

As an OTC product aspirin is not routinely As an OTC product aspirin is not routinely administered viaadministered via writtenwritten prescription prescription

Why is ASA Treatment Why is ASA Treatment DocumentationDocumentation so Poor? so Poor?

Although DHS provides an OTC aspirin Although DHS provides an OTC aspirin benefit for Medicaid patients, benefit for Medicaid patients, CMS does CMS does notnot cover OTC cover OTC products for Part D-Medicare patientsproducts for Part D-Medicare patients

Why is Aspirin Treatment Why is Aspirin Treatment DocumentationDocumentation so Poor? so Poor?

While providers While providers may may prescribe aspirin for prescribe aspirin for eligible patients they are:eligible patients they are:

Why is Aspirin Treatment Why is Aspirin Treatment DocumentationDocumentation so Poor? so Poor?

Largely unaware of the benefit and Largely unaware of the benefit and Unlikely to remember to use itUnlikely to remember to use itCommon reason for non-use:Common reason for non-use:

Majority of patients seen by providers Majority of patients seen by providers don’t need or cannot make use of an don’t need or cannot make use of an

aspirin prescription - it’s just aspirin prescription - it’s just notnot something something a busy provider will automatically think ofa busy provider will automatically think of

Providers ≠ PhysiciansProviders ≠ Physicians Providers include:Providers include: Physicians Physicians

MDsMDsDOsDOs

Mid Level Providers (MLPs)Mid Level Providers (MLPs)Physician AssistantsPhysician AssistantsNurse Practitioners Nurse Practitioners

Advanced Practice NursesAdvanced Practice Nurses

Workable solutions for this problem Workable solutions for this problem mustmust include include allall care providers care providers

So how do we make So how do we make a measurable improvement?a measurable improvement?

Educating Educating allall Minnesota providers to write Minnesota providers to write OTC aspirin prescriptions for OTC aspirin prescriptions for allall eligible eligible patients will prove a difficult taskpatients will prove a difficult task

Getting Getting allall eligible patients to submit this eligible patients to submit this prescription may also prove difficultprescription may also prove difficultThey may already have aspirin at homeThey may already have aspirin at homeThey may forget to bring the prescription They may forget to bring the prescription

since it is not required to obtain the since it is not required to obtain the medication and aspirin is inexpensivemedication and aspirin is inexpensive


Clinicians will often provide what a patient Clinicians will often provide what a patient requests requests Such as an aspirin prescriptionSuch as an aspirin prescription


Care Coordinators can help by ensuring all Care Coordinators can help by ensuring all eligible patients are aware of the benefiteligible patients are aware of the benefit

Patients must understand their use of the Patients must understand their use of the aspirin prescription benefit will also aspirin prescription benefit will also document their receipt of Best Caredocument their receipt of Best Care

Assisting the clinician with the Assisting the clinician with the name/fax+phone number of the patient’s name/fax+phone number of the patient’s preferred pharmacy might expedite the preferred pharmacy might expedite the processprocess


While the preferred contact with the While the preferred contact with the provider is an office visit, situations will provider is an office visit, situations will arise in which patient transport or provider arise in which patient transport or provider availability limit access within a reasonable availability limit access within a reasonable timeframetimeframe

This may result in a phone contact This may result in a phone contact whether from the patient or the coordinator whether from the patient or the coordinator in order to obtain the prescriptionin order to obtain the prescription


Assisting the clinician’s office staff by Assisting the clinician’s office staff by providing 2 patient identifiers, such as providing 2 patient identifiers, such as name and birthdate as well the fax + name and birthdate as well the fax + phone number of the patient’s preferred phone number of the patient’s preferred pharmacy may expedite and reduce the pharmacy may expedite and reduce the hassle of another office callhassle of another office call


In process improvement an average In process improvement an average solution that is very well executed will solution that is very well executed will always beat a better solution that is not always beat a better solution that is not well disseminated or multiple conflicting well disseminated or multiple conflicting solutionssolutions


Work hardWork hardNever give upNever give upIf the first plan fails consider If the first plan fails consider

alternative solutionsalternative solutions

Why We Fight…Why We Fight…

to improve healthcareto improve healthcare

Why We FightWhy We Fight

Minnesota is Minnesota is thethe national leadernational leader in reducing cardiovascular death in reducing cardiovascular death

without peerwithout peer


This success is shared by our This success is shared by our hardworkinghardworking & & healthy general healthy general populationpopulation

It includes public health success It includes public health success in reducing smoking rates and in reducing smoking rates and second-hand smokesecond-hand smoke


It also includes our progressive It also includes our progressive employers who realize the benefits of employers who realize the benefits of insuring for a healthy workforceinsuring for a healthy workforce

And our managed care organizations And our managed care organizations who have stressed preventive who have stressed preventive services and healthy lifestyles services and healthy lifestyles to reduce the costs of to reduce the costs of disease managementdisease management


Along with our tireless providers: Along with our tireless providers:

physicians, mid-levels, and nursesphysicians, mid-levels, and nurses

who have embraced evidence-based who have embraced evidence-based medicine and stressed broad medicine and stressed broad application of guideline indicated application of guideline indicated therapies across diverse patient therapies across diverse patient populationspopulations


Our hospitals that have focused on Our hospitals that have focused on coordinatedcoordinated,, fast and efficient care fast and efficient care with a with a passionpassion to reduce to reduce medical errormedical error


And finallyAnd finally,,

our informed and educated patients our informed and educated patients who ask the right questions and are who ask the right questions and are fully vested in seeing they receive fully vested in seeing they receive optimal healthcareoptimal healthcare


But our work isn’t finished until we But our work isn’t finished until we fully address one of the fully address one of the greatest greatest discriminations against the discriminations against the poor of our state - poor of our state -


But our work isn’t finished until we But our work isn’t finished until we fully address one of the greatest fully address one of the greatest discriminations against the discriminations against the poor of our state - poor of our state -

poor healthcarepoor healthcare

Promoting the use of the OTC Promoting the use of the OTC aspirin benefit in covered Medicaid aspirin benefit in covered Medicaid

seniorsseniors

Is a big step in the continuing Is a big step in the continuing effort to provide superior effort to provide superior

healthcare to healthcare to allall Minnesotans Minnesotans

Good Luck with your projectGood Luck with your project

Improving the Improving the documenteddocumented use of use of aspirin in MSHO/MSC/MSC+ aspirin in MSHO/MSC/MSC+

seniors with diabetes or ischemic seniors with diabetes or ischemic heart diseaseheart disease

QuestionsQuestions

2008 performance improvement project: improving the documented use of aspirin in msho/msc/msc+...

Documents

senior otc aspirin benefit

cardiovascular disease

claims data aspirin

documented use of aspirin

senior medicaid patients

care of patients

trial of aspirin therapy

minnesota senior care